CQC investigation finds improvements at Pilgrim Hospital but further progress still needed to protect patients

3 November 2011

The Care Quality Commission (CQC) has today published its investigation report into United Lincolnshire Hospitals NHS Trust.

The investigation into Pilgrim Hospital found there have been positive developments following previous feedback from CQC, such as new systems to strengthen frontline management and leadership.

CQC's investigation also found there is still more that needs to be done to protect patients from the risk of poor care.

Issues remain in monitoring the quality of care, the recruitment and retention of medical and nursing staff, and investigating and learning from serious incidents.

CQC launched the investigation in June following a series of serious incidents and two unannounced inspections of Pilgrim Hospital, both of which identified concerns.

The investigation looked closely at whether systems and procedures at the trust are good enough to ensure patients are guarded against inappropriate or unsafe care and treatment.

The investigation found the trust is addressing some problems previously highlighted by CQC but the trust needs to provide further assurance that it is doing enough to achieve sustainable improvements. CQC has made 21 recommendations that the trust must fulfil and which will be monitored through unannounced inspections.

These recommendations include more effective management of risk and serious incidents, a swifter response to and fuller investigation of complaints and better focus on safeguarding patients from abuse by learning from investigations and ensuring staff are properly trained.

CQC’s investigation found:

poor quality care and clinical errors had resulted in a number of complaints and serious incidents.

the trust was slow to respond to, investigate, and resolve complaints and serious incidents.

cultural issues, including a fast turnover in leadership in some areas, were found to have hampered progress for implementing improvements.

inadequate systems for monitoring patients’ experiences.

issues in recruiting medical staff meant the trust was reliant on locum staff - which had additional cost implications.

the NHS East Midlands Strategic Health Authority (SHA) and the NHS Lincolnshire Primary Care Trust (PCT) needed to do more to identify risks at Pilgrim Hospital and take the appropriate action.

Andrea Gordon, CQC Regional Director in the East and West Midlands, said: “United Lincolnshire Hospitals NHS Trust is making improvements, however we are not satisfied yet that enough has been done to ensure the trust is compliant with the essential standards of quality and safety.

“The trust had been slow to investigate incidents and follow up complaints from patients and their families. This is a cause of real concern for CQC. It is important for any trust to act swiftly regarding these matters and make sure that, where necessary, it learns quickly and resolves issues.

“The investigation also highlighted staffing issues and the use of locums, which had been costly for the trust. There have also been a number of changes in leadership across the trust and it needs to bring about stability in order to help cement any changes made.

“It is not just the trust that needs to effect change, the PCT and SHA also need to be more robust in their monitoring.”

The CQC also recommended that the PCT takes a more rigorous approach in checking on the experiences of patients and a stronger approach to its performance management of the trust’s complaints, patient safety and safeguarding adults.

Recommendations for the SHA include ensuring the trust has a strong action plan to prevent a recurrence of issues highlighted in recent NHS Ombudsman reports in relation to complaints about the trust.

Andrea Gordon added: “Pilgrim Hospital remains under CQC’s scrutiny and we will be carrying out further unannounced inspections and reviewing information about the trust to assess its progress in bringing about real and sustainable improvement in patient care.”

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